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from its web site at www.dir.ca.gov. These regulations are for the
convenience of the user and no representation or warranty is made that the information
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§ 9702. Electronic Data Reporting.

(a) Each claims administrator shall transmit data elements, by electronic data interchange in the manner set forth in the California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records, to the WCIS by the dates specified in this section. Each claims administrator shall, at a minimum, provide complete, valid, accurate data for the data elements set forth in this section. The data elements required in subdivisions (b), (c), (d) and (e) are taken from California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records. Claims administrators shall only transmit the data elements that are set forth in the California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records. Each transmission of data elements shall include appropriate header and trailer records as set forth in the California EDI Implementation Guide for First and Subsequent Reports of Injury and the California EDI Implementation Guide for Medical Bill Payment Records.

(1) The Administrative Director, upon written request, may grant a claims administrator either a partial or total variance in reporting all or part of the data elements required pursuant to subdivision (e) of this section. Any variance granted by the Administrative Director under this subdivision shall be set forth in writing.

(A) A partial variance requested on the basis that the claims administrator is unable to transmit some of the required data elements to the WCIS shall be granted for a six month period only if all of the following are shown:

1. a documented showing that compliance with the reporting deadlines set forth in subdivision (e) would cause undue hardship to the claims administrator;

2. a documented showing that any medical data elements currently being transmitted by the claims administrator or the claims administrator's agent to public or private research or statistical entities shall be reported by the claims administrator to the WCIS; and

3. submission of a plan, prior to the applicable deadline set forth in subdivision (e), documenting the means by which the claims administrator will ensure full compliance with the data reporting within six months from the request.

(B) A partial variance requested on the basis that the claims administrator is unable to report some of the required data elements to the WCIS because the data elements are not available to the claims administrator or the claims administrator's agent shall be granted for a six month period only if all of the following are shown:

1. a documented showing that compliance with the reporting deadlines set forth in subdivision (e) would cause undue hardship to the claims administrator;

2. a documented showing that any medical data elements currently being transmitted by the claims administrator or the claims administrator's agent to public or private research or statistical entities shall be reported by the claims administrator to the WCIS;

3. a documented showing that the claims administrator will submit to the WCIS the medical data elements available to the claims administrator or the claims administrator's agents; and

4. submission of a plan, prior to the applicable deadline set forth in subdivision (e), documenting the means by which the claims administrator will ensure full compliance with the data reporting within six months from the request.

(C) A total variance shall be granted for a twelve month period if all of the following are shown:

1. a documented showing that compliance with the reporting deadlines set forth in subdivision (e) would cause undue hardship to the claims administrator;

2. a documented showing that the claims administrator has not contracted with a bill review company to review medical bills submitted by providers in its workers' compensation claims;

3. a documented showing that the claims administrator is unable to transmit medical data to public or private research or statistical entities; and

4. submission of a plan, prior to the applicable deadline set forth in subdivision (e), documenting the means by which the claims administrator will ensure full compliance with the data reporting within twelve months from the request.

(2) “Undue hardship” shall be determined based upon a review of the documentation submitted by the claims administrator. The documentation shall include: the claims administrator's total required expenses; the reporting cost per claim if transmitted in house; and the total cost per claim if reported by a vendor. The costs and expenses shall be itemized to reflect costs and expenses related to reporting the data elements listed in subdivision (e) only.

(3) The variance period for reporting data elements under subdivisions (a)(1)(A) and (B) shall not be extended. The variance period for reporting data elements under subdivision (a)(1)(C) may be extended for additional twelve month periods if the claims administrator resubmits a written request for a variance. A claims administrator granted a variance shall submit to the WCIS all data elements that were required to be submitted under subdivision (e) during the variance period except for data elements that were not known to the claims administrator, the claims administrator's agents, or not captured on the claims administrator's electronic data systems. The data shall be submitted in an electronic format acceptable to the Division.

(b) Each claims administrator shall submit to the WCIS on each claim, within ten (10) business days of knowledge of the claim, each of the following data elements known to the claims administrator:

(2) The Agency/Jurisdiction Claim Number (DN 5) will be provided by WCIS upon receipt of the first report under subdivision (b). The Agency/Jurisdiction Claim Number (DN 5) is required when changing a Claim Administrator Claim Number (DN 15); it is optional for other transmissions under this subsection.

(3) The Date of Injury (DN 31), Social Security Number (DN 42), and Claim Administrator Claim Number (DN 15) need not be submitted if the Agency/Jurisdiction Claim Number (DN 5) accompanies the transmission, except for transmissions required under Subsection (f). If the Social Security Number (DN 42) is not known, use a string of eight zeros followed by a six.

(4) If the Agency/Jurisdiction Claim Number (DN 5) is not provided, trading partners must provide the Claim Administrator Claim Number (DN 15) and the Third Party Administrator FEIN (DN 8), or, if there is no third party administrator, the Insurer FEIN (DN 6).

(d) Each claims administrator shall submit to the WCIS within fifteen (15) business days the following data elements, whenever indemnity benefits of a particular type and amount are started, changed, suspended, restarted, stopped, delayed, or denied, or when a claim is closed or reopened, or when the claims administrator is notified of a change in employee representation. Submissions under this subsection are required only for claims with a date of injury on or after July 1, 2000, and shall not include data on routine payments made during the course of an uninterrupted period of indemnity benefits.

(2) Use actual permanent disability rating at the time of initial payment of permanent disability benefits. For compromise and release cases and stipulated settlements, use permanent disability estimate as reported to the appropriate rating organization established under Insurance Code § 11750, et seq.

(e) On and after September 22, 2006, claims administrators handling one hundred and fifty (150) or more total claims per year shall submit to the WCIS on each claim with a date of service on or after September 22, 2006, the following data elements for all medical services for which the claims administrator has received a billing or other report of provided medical services. The California EDI Implementation Guide for Medical Bill Payment Records sets forth the specific California reporting requirements. The data elements required in this subdivision are taken from California EDI Implementation Guide for Medical Bill Payment Records and the IAIABC EDI Implementation Guide for Medical Bill Payment Records. The claims administrator shall submit the data within ninety (90) calendar days of the medical bill payment or the date of the final determination that payment for billed medical services will be denied. Each claims administrator shall submit all medical lien lump sum payments or settlements following the filing of a lien claim for the payment of such medical services pursuant to Labor Code sections 4903 and 4903.1 within ninety (90) calendar days of the medical lien lump sum payment or settlement. Each claims administrator shall transmit the data elements by electronic data interchange in the manner set forth in the California EDI Implementation Guide for Medical Bill Payment Records and the IAIABC EDI Implementation Guide for Medical Bill Payment Records.

Data Element Name

DN

ACKNOWLEDGMENT TRANSACTION SET ID

110

ADMISSION DATE (17)

513

ADMITTING DIAGNOSIS CODE

535

APPLICATION ACKNOWLEDGMENT CODE

111

BASIS OF COST DETERMINATION CODE

564

BATCH CONTROL NUMBER

532

BILL ADJUSTMENT AMOUNT (17)

545

BILL ADJUSTMENT GROUP CODE (5)(17)

543

BILL ADJUSTMENT REASON CODE (17)

544

BILL ADJUSTMENT UNITS (17)

546

BILL SUBMISSION REASON CODE

508

BILLING FORMAT CODE

503

BILLING PROVIDER FEIN

629

BILLING PROVIDER LAST/GROUP NAME

528

BILLING PROVIDER NATIONAL PROVIDER ID (17)

634

BILLING PROVIDER POSTAL CODE

542

BILLING PROVIDER PRIMARY SPECIALTY CODE (4)

537

BILLING PROVIDER STATE LICENSE NUMBER (4)(7)

630

BILLING PROVIDER UNIQUE BILL IDENTIFICATION

NUMBER

523

BILLING TYPE CODE (17)

502

CLAIM ADMINISTRATOR CLAIM NUMBER

15

CLAIM ADMINISTRATOR FEIN

187

CLAIM ADMINISTRATOR NAME

188

CONTRACT TYPE CODE

515

DATE INSURER PAID BILL (9)(11)

512

DATE INSURER RECEIVED BILL (12)

511

DATE OF BILL (17)

510

DATE OF INJURY

31

DATE PROCESSED

108

DATE TRANSMISSION SENT

100

DAYS/UNITS BILLED (17)

554

DAYS/UNITS CODE (17)

553

DIAGNOSIS POINTER

557

DISCHARGE DATE (17)

514

DISPENSE AS WRITTEN CODE

562

DME BILLING FREQUENCY CODE

567

DRG CODE

518

DRUG NAME

563

DRUGS/SUPPLIES BILLED AMOUNT

572

DRUGS/SUPPLIES DISPENSING FEE

579

DRUGS/SUPPLIES NUMBER OF DAYS

571

DRUGS/SUPPLIES QUANTITY DISPENSED

570

ELEMENT ERROR NUMBER

116

ELEMENT NUMBER

115

EMPLOYEE FIRST NAME

44

EMPLOYEE LAST NAME

43

EMPLOYEE MIDDLE NAME/INITIAL

45

EMPLOYEE EMPLOYMENT VISA

152

EMPLOYEE GREEN CARD

153

EMPLOYEE PASSPORT NUMBER

156

EMPLOYEE SOCIAL SECURITY NUMBER (10)

42

FACILITY CODE

504

FACILITY FEIN

679

FACILITY MEDICARE NUMBER

681

FACILITY NAME (17)

678

FACILITY NATIONAL PROVIDER ID (17)

682

FACILITY POSTAL CODE (17)

688

FACILITY STATE LICENSE NUMBER (7)

680

HCPCS BILL PROCEDURE CODE

737

HCPCS LINE PROCEDURE BILLED CODE

714

HCPCS LINE PROCEDURE PAID CODE

726

HCPCS MODIFIER BILLED CODE

717

HCPCS MODIFIER PAID CODE

727

HCPCS PRINCIPLE PROCEDURE BILLED CODE

626

ICD-9 CM DIAGNOSIS CODE

522

ICD-9 CM PRINCIPAL PROCEDURE CODE

525

ICD-9 CM PROCEDURE CODE

736

INSURER FEIN

6

INSURER NAME

7

INTERCHANGE VERSION ID

105

JURISDICTION CLAIM NUMBER

5

JURISDICTION MODIFIER BILLED CODE (8)(10)

718

JURISDICTION MODIFIER PAID CODE (8)

730

JURISDICTION PROCEDURE BILLED CODE (8)(13)(17)

715

JURISDICTION PROCEDURE PAID CODE (8)(9)(13)

729

LINE NUMBER (18)

547

MANAGED CARE ORGANIZATION FEIN (1)(17)

704

MANAGED CARE ORGANIZATION IDENTIFICATION

NUMBER

208

MANAGED CARE ORGANIZATION NAME

209

MANAGED CARE ORGANIZATION POSTAL CODE

712

NDC BILLED CODE (17)

721

NDC PAID CODE

728

ORIGINAL TRANSMISSION DATE

102

ORIGINAL TRANSMISSION TIME

103

PLACE OF SERVICE BILL CODE (17)

555

PLACE OF SERVICE LINE CODE (17)

600

PRESCRIPTION BILL DATE

527

PRESCRIPTION LINE DATE

604

PRESCRIPTION LINE NUMBER

561

PRINCIPLE DIAGNOSIS CODE (17)

521

PRINCIPLE PROCEDURE DATE

550

PROCEDURE DATE

524

PROVIDER AGREEMENT CODE (3)

507

RECEIVER ID

99

REFERRING PROVIDER NATIONAL PROVIDER ID (17)

699

RELEASE OF INFORMATION CODE (17)

526

RENDERING BILL PROVIDER COUNTRY CODE (17)

657

RENDERING BILL PROVIDER FEIN

642

RENDERING BILL PROVIDER LAST/GROUP NAME

638

RENDERING BILL PROVIDER NATIONAL PROVIDER

ID (7)(17)

647

RENDERING BILL PROVIDER POSTAL CODE

656

RENDERING BILL PROVIDER PRIMARY SPECIALTY

CODE (17)

651

RENDERING BILL PROVIDER SPECIALTY LICENSE

NUMBER (7)

649

RENDERING BILL PROVIDER STATE LICENSE

NUMBER (7)(17)

643

RENDERING LINE PROVIDER NATIONAL PROVIDER

ID (7)(17)

592

RENDERING LINE PROVIDER FEIN

586

RENDERING LINE PROVIDER LAST/GROUP NAME (6)

589

RENDERING LINE PROVIDER POSTAL CODE

593

RENDERING LINE PROVIDER PRIMARY SPECIALTY

CODE (6)

595

RENDERING LINE PROVIDER STATE LICENSE

NUMBER (6)(7)

599

REPORTING PERIOD

615

REVENUE BILLED CODE

559

REVENUE PAID CODE

576

SENDER ID

98

SERVICE ADJUSTMENT AMOUNT (17)

733

SERVICE ADJUSTMENT GROUP CODE (5)(17)

731

SERVICE ADJUSTMENT REASON CODE (5)(17)

732

SERVICE ADJUSTMENT UNITS (17)

734

SERVICE BILL DATE(S) RANGE (14)

509

SERVICE LINE DATE(S) RANGE (9)(17)

605

SUPERVISING PROVIDER NATIONAL PROVIDER ID (17)

667

TEST/PRODUCTION INDICATOR

104

TIME PROCESSED

109

TIME TRANSMISSION SENT

101

TOTAL AMOUNT PAID PER BILL (2)(15)

516

TOTAL AMOUNT PAID PER LINE (2)(17)

574

TOTAL CHARGE PER BILL (16)

501

TOTAL CHARGE PER LINE - PURCHASE

566

TOTAL CHARGE PER LINE - RENTAL

565

TOTAL CHARGE PER LINE (17)

552

TRANSACTION TRACKING NUMBER

266

UNIQUE BILL ID NUMBER

500

______________

(1) For HCO claims use the FEIN of the sponsoring organization in DN 704.

(7) To be provided if available. The National Provider Identifier is assigned by the United States Department of Health and Human Services, Centers for Medicare & Medicaid Services ( “CMS”).

(8) Use codes that are either set forth and/or incorporated by reference in California Code of Regulations, title 8, section 9795, regarding reasonable fees for medical-legal expenses, and section 9789.11, regarding fees for physician services rendered after January 1, 2004.

(9) For payments made pursuant to California Code of Regulations, title 8, section 10536, the data edit date the insurer paid the bill (DN 512) must be >= date the insurer received the bill (Error Code 073 is waived to allow payment of services); the data edit service line date(s) range (DN 605) must be <= the current date (Error Code 041 is waived to allow payment of services).

(10) If the Employee is not a United States citizen and has no other form of identification (DN 153, DN 152, or DN 156), use either a string of eight zeros followed by a six or a string of nine consecutive nines.

(11) For medical lien lump sum payments or settlements use the date final payment was made.

(12) For medical lien lump sum payments or settlements use the date on the first medical bill received.

(13) Use the following codes for reporting a medical lien lump sum payment or settlement:

MDS10 Lump sum payment or settlement for multiple bills where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.

MDO10 Final order or award of the Workers' Compensation Appeals Board requires a lump sum payment for multiple bills where the amount of reimbursement is in dispute between the claims payer and the healthcare provider

MDS11 Lump sum payment or settlement for multiple bills where liability for a claim was denied but finally accepted by the claims payer

MDO11 Final order or award of the Workers' Compensation Appeals Board requires a lump sum payment for multiple bills where claims payer is found to be liable for a claim which it had denied liability.

MDS21 Lump sum payment or settlement for a single medical bill where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.

MDO21 Final order or award of the Workers' Compensation Appeals Board requires a lump sum payment for a single medical bill where the amount of reimbursement is in dispute between the claims payer and the healthcare provider.

(14) For a medical lien lump sum payment or settlement use the date of lien filing.

(15) For a medical lien lump sum payment or settlement use the settled or ordered amount.

(16) For a medical lien lump sum payment or settlement use the amount in dispute.

(17) Not required for a mixed medical lien lump sum payment or settlement.

(f) Notwithstanding the requirement in Subsection (b) to submit data elements omitted from the first report within 60 days from the date of transmission of the first report, when a claims administrator becomes aware of an error or need to update data elements previously transmitted, or learns of information that was previously omitted, the claims administrator shall transmit the corrected, updated or omitted data to WCIS no later than the next submission of data for the affected claim.

(g) No later than January 31 of every year, claims administrators shall report for each claim the total paid in any payment category in the previous calendar year by submitting the following data elements:

Data Element Name

DN

PAID TO DATE/REDUCED EARNINGS/RECOVERIES AMOUNT

96

PAID TO DATE/REDUCED EARNINGS/RECOVERIES CODE

95

PAYMENT/ADJUSTMENT CODE

85

PAYMENT/ADJUSTMENT END DATE

89

PAYMENT/ADJUSTMENT PAID TO DATE

86

PAYMENT/ADJUSTMENT START DATE

88

(h) Final reports (MTC = FN) are required only for claims where indemnity benefits are paid. For medical-only claims, the final report may be reported under this section or on the annual report (MTC = AN) with claim status = “closed.”

(i)(1) A claims administrator's obligation to submit copies of benefit notices to the Administrative Director pursuant to Labor Code section 138.4 is satisfied upon written determination by the Administrative Director that the claims administrator has demonstrated the capability to submit complete, valid, and accurate data as required under subdivision (d) and continued compliance with that subsection.

(2) Reserved.

(3) On and after September 22, 2006, a claims administrator's obligation to submit an Annual Report of Inventory pursuant to California Code of Regulations, title 8, section 10104 is satisfied upon determination by the Administrative Director that the claims administrator has demonstrated the capability to submit complete, valid, and accurate data as required under subdivisions (b), (d), (e), and (g), and continued compliance with those subsections.

(j) The data submitted pursuant to this section shall not have any application to, nor be considered in, nor be admissible into, evidence in any personal injury or wrongful death action, except as between an employee and the employee's employer. Nothing in this subdivision shall be construed to expand access to information held in the WCIS beyond that authorized in California Code of Regulations, title 8, section 9703 and Labor Code section 138.7.

(k) Each claims administrator required to submit data under this section shall submit to the Administrative Director an EDI Trading Partner Profile at least thirty days prior to its first transmission of EDI data. Each claims administrator shall advise the Administrative Director of any subsequent changes and/or corrections made to the information provided in the EDI Trading Partner Profile by filing a corrected copy of the EDI Trading Partner Profile with the Administrative Director.